The poster child for this tsunami of mergers is the £1bn giant being formed in east London, but the key merger trend may turn out to be the linking up of smaller equals. Medway Foundation Trust’s takeover of Dartford and Gravesham should create an organisation big enough to survive, as will the combination of Poole and Bournemouth.

Even where mergers are not taking place there is steady disaggregation of services between hospitals, often to private and voluntary providers. In fact, the Barometer’s clearest message is of a divide between winners and losers. Even where smaller trusts are not being gobbled up many face a steady reduction in services.

The efficiency drive has combined with the movement of all trusts to foundation status to spark this great rationalisation.

The boards of many acutes around the £100m-turnover mark had hoped they could make it as independent foundation trusts. Very few have been allowed to try and none without community services. Staff costs, tariff reductions and shifting resources to primary care all conspire against the optimists at the smaller trusts.

Many of the Barometer’s respondents complain about the growing demands of the FT application process. The bad news for them is that, in the wake of problems at Morecambe Bay and, possibly, in anticipation of the conclusions of the Francis inquiry into Mid Staffordshire Foundation Trust, that assessment is going to get even tougher. It is also increasingly clear there are a significant number of smaller foundation trusts that face a very challenging future and would not pass assessment were they applying now.

Monitor – and the Department of Health – will wish to avoid de-authorisation at all costs and this is very likely to encourage the regulator to increase its intervention in struggling foundations. Again, mergers are likely to be the answer proposed.

The DH – directly through strategic health authorities and indirectly with Monitor – is overseeing the reshaping of the acute sector. But we will soon be living in a different world, with the DH exercising influence through an annual mandate.

The scale and speed of change requires careful oversight and sometimes rapid reaction. In the future different elements of this change will be in the hands of Monitor (still struggling with its new regulatory role), the NHS Commissioning Board, clinical commissioning groups, the Care Quality Commission, health and wellbeing boards and the Trust Development Authority.

These bodies all have requirements to cooperate, but also to maintain independence. How and when they should work together is still to be determined and tested. The future of England’s hospitals depends on an effective solution being found by the end of the year.

Interesting concept of creating massive providers and breaking up commissioners into smaller units. It does not sound like a fair fight will be had and the larger may well ignore the smaller (as they do now).

Didin't we have large NHS entities 20 years ago. I think they were called health authorities? What happened to local involvement? Also, how will concept of the market work in the face of what could become geographic monoplies?

Actually, as a newcomer to the NHS it always struck me as odd that there were no regional or national hospital chains, as there are in most other industries.

I dont think this has anything to do with, as the editorial suggests, the new system. If anything the new system will lead to less of these things as there is no real strategic system leader in the new world.

No. These mergers are mainly driven by lower financial settlements played out through tariff reductions.

The one thing they have in their favour is at least being able to be developed at run by the organisations themselves, compared to the commissioning changes which are subject to a poorly run pseudo national process.

Who says the driver of mergers is efficiency. It is more likely to be cost and control of the 'market'. Leviathan FT's will tell CCG's what they can and cant have and patients had better keep their figures crossed. Organisational Darwinism when intelligent design is needed!

NHS management continue to delude themselves that big mergers and or shared services are the answer to the Nicholson challenge. Look at South London healthcare Trust (as 1 of many examples) - has the merger of troubled trusts led to an improvement or worsening of the situation.

The problem in the NHS acute sector is around poor process as a consequence of poor management, poorly aligned incentives, low staff morale etc. the NHS should focus on the root cause problems, not look for a false silver bullet in mergers like this

The whole point of all these mergers and "efficiency drives" is they have nothing whatsoever to do with being more efficient or improving care for patients, they are there to dismantle the NHS completely, drive through private care, even though private insurers are losing money hand over fist and have stopped funding new hospital projects and patient care. This is policy based on ideology from the 1980's. Jane Hautot is one of many, like myself who remembers local hospitals that were shut during the Thatcher years, South London Hospital for Women & Children was one, another was St James' in Balham, along with the Garrett Anderson, a small cottage hospital my mother spent some time in after a difficult pregnancy with my youngest brother. All gone in the name of "efficiency and offering more patient choice". Sound familiar? It ought to be. This bunch of second hand car dealers are the same as they were then and they're just finishing the job that was started then. When are we going to wake up and protest about it? When we all have to have private health cover or before then????

The proof of the pudding is in the eating, and below is an example of the levels of efficiency which can be achieved by merging two NHS Trusts.

The HSJ reported in October last year about the CQC investigating an atypical Rise in Never Events at the Trust; a Trust which exists as the result of a merger between two hospital Trusts in 2006.

The article reported: ‘The minutes, from a July meeting, say [The County PCT] director of quality and governance “felt the main cause of the increase in never events at [The Trust] was that learning from previous never events was not embedded across the trust due to the size of the organisation”.

The investigation of never events at the Trust wasn’t an isolated report, but just one of an increasing number of negative reports of the (merged) Trust in the press over the past year.

These reports included breaching the number of clostridium difficile cases in February 2011 (HSJ), failing to meet standards in four areas of consent in an inspection by the Human Tissue Authority in March 2011 (Report on HTA Website), and being 154th out of 163 trusts for assessing patients for their risk of developing potentially life-threatening blood clots in May 2011 (Local Press Website). October was a busy month for the Trust, which as well as them being under investigation for the high number of Never Events (HSJ), also saw the Trust identified as the worst Trust in the country for breaching patient confidentiality (Local Press Website), as well as a freedom of information request showing they had increased their sickness-related dismissals of staff by 5,500% in two years (‘What do they know’ website). Perhaps even more telling is the that in November 2011 one of the two hospitals was identified as the least popular Hospital in the whole country in the 2011 Dr Foster Hospital Guide, with a mere 20% of its patients able to recommend it, and the same report identified the Trust as one of nine Trusts with the highest weekend mortality rates in the country. And finally, in December the Trust was reported as having failed to meet the required standards in 8 out of 10 quality targets by the Care Quality Commission (BBC Local Website).

This year doesn’t appear to be any better. In January the Trust had exceeded A&E assessment times by 100% with assessments taking 32 minutes as opposed to the targeted 15 minutes (HSJ). In the same month they were under close scrutiny, again because of the number of never events, there having been five in 2011/2012 (HSJ), and last month for having cancelled more than 300 operations, with 185 of those in January alone (Local Press Website).

Since 2008 the Trust has been publicly proclaiming its “vision” of being the very best Acute Teaching Trust in the whole of the NHS by 2016, and despite the fact that a 5,500% increase in sick staff might imply otherwise, have a second “vision” of being the very best employer in the whole of the NHS (and the whole of the city), also by 2016. The Trust has even made a public pledge, both to patients and to staff: “We are here for you”, those five words commonly being printed on the bottom letterhead of the dismissal letters of sick staff.

Interestingly, the Director of Workforce & Strategy who justifies these dismissals of ill staff by what he has referred to as ”A more robust use of policy” is also the Vice-Chair of the Policy Board of NHS Employers, which according to their website “The policy board provides a steer on the direction of travel for both the organisation and policy development”.

Dismissing sick staff would certainly seem to be a very effective way of going some way to achieving the Trust’s sickness and absence targets, which have still not been achieved. It may also have something to do with the fact that last year the Trust were reporting an adverse variance on pay expenditure of £3.6m (HSJ). This might also explain, perhaps, the fact that out of all dismissals, less than one in five of dismissed staff are replaced, according to figures given to the union by the Trust’s HR department.

In the Trust's Annual Plan 2011/2012, it reflects on the previous year as “another year of significant progress in the journey towards becoming the best acute teaching Trust by 2016”. We will have to wait for the Annual Plan 2012/2013 to see if the Trust views 2011/2012 as even further significant progress in their journey towards their vision.

Is the tsunami of mergers going to be the tip of the iceberg for hospital failures? Time and again, evidence in both the business and healthcare literature has pointed out the high failure rate of mergers and acquisitions (M&A) - failure both in terms of cost improvement as well as business/clinical outcomes. And the key reason for failure is often a difference in organisational culture, especially as the organisation that 'takes over' tries to put its stamp on the 'taken over'. Yet, despite this evidence, the NHS carries on merging regardless. So much for evidence-based healthcare policy.

The more they merge the harder it is to monitor quality remotely since too much information is captured against the trust rather than the hospital. Even the PAS patient record that should be recorded against the hospital (via the site of treatment field) is often coded to the head office or some other seemingly randomly selected individual site irrespective of where the care is provided. Some trusts are able to divvy up the data using local patient identifiers and the like for their own use, others aren't, either way remote monitoring of anything becomes high on impossible.

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